Calcaneal Bursitis 

Updated: Sep 12, 2019
Author: Patrick M Foye, MD; Chief Editor: Consuelo T Lorenzo, MD 

Overview

Background

Pain at the posterior heel or posterior ankle is most commonly caused by pathology at the posterior calcaneus, the Achilles (calcaneal) tendon, or the associated bursae. The following bursae are located just superior to the insertion of the Achilles tendon[1, 2, 3] :

  • Subtendinous calcaneal bursa - This bursa (also called the retrocalcaneal bursa), situated anterior (deep) to the Achilles tendon, is located between the Achilles tendon and the calcaneus.[4]

  • Subcutaneous calcaneal bursa - Also called the Achilles bursa, it is found posterior (superficial) to the Achilles tendon, lying between the skin and the posterior aspect of the distal Achilles tendon.

Inflammation of one or both of these bursae can cause pain in the posterior heel and ankle regions.[5, 6]  Similarly, patients with Achilles tendinopathy may also have a thickened subcutaneous bursa with increased blood flow in the bursa walls. Concurrent Achilles tendon and subcutaneous bursa pathology can be very painful, as the subcutaneous bursa is a well-innervated structure and may be responsible for a great deal of pain.[7]

Haglund deformity (prominence of the posterior superior calcaneus) is not a true synonym for calcaneal bursitis, but it can be a closely associated condition.

For additional information, see Bursitis [Emergency Medicine], Bursitis [Orthopedic Surgery], and Retrocalcaneal Bursitis.

Pathophysiology

Inflammation of the calcaneal bursae is most commonly caused by repetitive overuse and cumulative trauma, as seen in runners wearing tight-fitting shoes. Such bursitis may also be associated with conditions such as gout, rheumatoid arthritis, and seronegative spondyloarthropathies.

In some cases, subtendinous calcaneal bursitis is caused by bursal impingement between the Achilles tendon and an excessively prominent posterior superior aspect of a calcaneus that has been affected by Haglund deformity. With Haglund disease, impingement occurs during ankle dorsiflexion.

A study by Lohrer and Nauck indicated that retrocalcaneal bursa pressure rises in patients with chronic retrocalcaneal bursitis, which in turn, the investigators suggested, can cause an impingement lesion on the anterior Achilles tendon.[8]

Epidemiology

Frequency

United States

Calcaneal bursitis is seen somewhat frequently, particularly if the clinician has a predominantly musculoskeletal practice.

Mortality/Morbidity

See the list below:

  • No mortality is associated with calcaneal bursitis.

  • Morbidity is associated with progressive pain and limping (antalgic gait) in patients who have not received adequate treatment. If chronic inflammation also affects the distal Achilles tendon, rupture of the tendon may occur.

Race

No race predilection has been documented.

Sex

Calcaneal bursitis is observed in men and women. However, some increased risk may be incurred by women who wear high-heeled shoes.

Age

Calcaneal bursitis is commonly observed in middle-aged and elderly persons; the condition is also seen in athletes of all ages.

 

Presentation

History

Obtaining a detailed history from the patient is important in diagnosing calcaneal bursitis.[9] The following complaints (which the physician should ask about during the subjective examination) are commonly reported by patients:

  • Posterior heel pain is the chief complaint in individuals with calcaneal bursitis.

  • Patients may report limping caused by the posterior heel pain.

  • Some individuals may also report an obvious swelling (eg, a pump bump, a term that presumably comes from the swelling's association with high-heeled shoes or pumps).

  • The condition may be unilateral or bilateral.

  • Symptoms are often worse when the patient first begins an activity after rest.

Other inquiries that the physician should make include the following:

  • The clinician should ask about the patient's customary footwear (whether, for example, it includes high-heeled shoes or tight-fitting athletic shoes).

    • The patient should be asked specifically about any recent change in footwear, such as whether he/she is wearing new athletic shoes or whether the patient has made a transition from flat shoes to high heels or vice versa. Individuals who have been accustomed to wearing high-heeled shoes on a long-term basis may find that switching to flat shoes causes increased stretch and irritation of the Achilles tendon and the associated bursae.

  • The specifics of a patient's activity level should be ascertained, including how far the patient runs and, in particular, whether the individual is running with greater intensity than before or has increased the distance being run.

  • The history of any known or suspected underlying rheumatologic conditions, such as gout, rheumatoid arthritis, or seronegative spondyloarthropathies, should be obtained.

Physical

During the physical examination of a patient with calcaneal bursitis, the physician should keep the following considerations in mind:

  • Swelling and redness of the posterior heel (the pump bump) may be clearly apparent.

  • The inflamed area, which may be slightly warm to the touch, is generally tender to palpation.

  • Careful examination can help the clinician to distinguish whether the inflammation is posterior to the Achilles tendon (within the subcutaneous calcaneal bursa) or anterior to the tendon (within the subtendinous calcaneal bursa). Differentiating Achilles tendinitis/tendinosis from bursitis may be impossible. At times, the 2 conditions co-exist.

  • Isolated subtendinous calcaneal bursitis is characterized by tenderness that is best isolated by palpating just anterior to the medial and lateral edges of the distal Achilles tendon.

  • Conversely, insertional Achilles tendinitis is notable for tenderness that is located slightly more distally, where the Achilles tendon inserts on the posterior calcaneus.

  • A patient with plantar fasciitis has tenderness along the posterior aspect of the sole, but he/she should not have tenderness with palpation of the posterior heel or ankle.[9]

  • A patient with a complete avulsion or rupture of the Achilles tendon demonstrates a palpable defect in the tendon, weakness in plantarflexion, and a positive Thompson test on physical examination. During the Thompson test, the examiner squeezes the calf. The test is negative if this maneuver results in passive plantarflexion of the ankle, which would indicate that the Achilles tendon is at least partially intact.

Causes

See the list below:

  • Overtraining in a runner (eg, excessive increases in miles or intensity)

  • Repetitive microtrauma and acute traumatic injury to the region[10]

  • Infections and inflammatory conditions such as gout and rheumatoid arthritis[10]  

  • Tight or poorly fitting shoes that, because of a restrictive heel counter, exert excessive pressure on the posterior heel and ankle

  • Haglund deformity, causing impingement between the increased posterior superior calcaneal prominence and the Achilles tendon during dorsiflexion

  • More recent research suggests that a misaligned subtalar joint axis (measured in terms of joint inclination and deviation) in relation to the Achilles tendon can result in an asymmetrical force load on the tendon, disrupting normal biomechanics. This altered joint axis is associated with an increased risk for Achilles pathologies, including bursitis.[11]

 

DDx

Diagnostic Considerations

These include the following:

  • Gout

  • Haglund deformity

  • Seronegative spondyloarthropathies

  • Stress fracture of the calcaneus

  • Sural neuritis

  • Medial calcaneal nerve impingement (branch of tibial nerve)

  • Achilles chondrocalcinosis

  • Calcaneal spur

  • Calcaneal osteochondroma

Differential Diagnoses

 

Workup

Laboratory Studies

If the appearance of the bursitis cannot be explained by local factors (eg, ill-fitting shoes, excessive running, high heels) or if there are systemic symptoms or signs of rheumatologic involvement, the clinician should consider laboratory studies to evaluate for the possibility of gout (hyperuricemia), rheumatoid arthritis (rheumatoid factor), and seronegative spondyloarthropathies (HLA B-27, erythrocyte sedimentation rate, and/or C-reactive protein).

Also see related Medscape Resource Centers on Gout and Rheumatoid Arthritis.

Imaging Studies

Plain radiographs of the calcaneus may reveal Haglund deformity, which can be seen best on the lateral view. In this view, the triad consistent with Haglund's disease is thickening of Achilles tendon at insertion, retrocalcaneal bursitis, and retro-Achilles bursitis.[12]

Plain radiographs can also be used to evaluate for stress fracture of the calcaneus. If the plain radiographs are negative for stress fracture but this injury possibility remains a significant diagnostic consideration, a 3-phase bone scan or a computed tomography (CT) scan of the calcaneus should be obtained.

Magnetic resonance imaging (MRI) scans may demonstrate bursal inflammation but probably do not offer much more information than is apparent from careful physical examination. Theoretically, MRI scans may help to determine whether the inflammation is in the subcutaneous calcaneal bursa, the subtendinous calcaneal bursa, or the tendon itself, but such testing is generally unnecessary.[13, 14]

Hybrid imaging modalities, most specifically single-photon emission CT (SPECT)/CT, may assist with early detection of bursitis by offering a precise, accurate, and highly localizing diagnostic image. However, little research exists on the cost benefit of this modality, and therefore, this imaging modality is not frequently used for this type of soft-tissue injury.[15]

Some clinicians have suggested that ultrasonography can be used in place of MRI in cases in which imaging is desired to investigate pathology at the posterior heel. A recent study concluded that extended field-of-view sonography (EFOVS) when combined with traditional gray-scale sonography has similar sensitivity and specificity to MRI for diagnosing calcaneal bursitis in addition to more rapid results, lower cost, and lack of contraindications.[16, 17, 18]

Procedures

Generally, no diagnostic procedures are required.

Histologic Findings

Bursal inflammation is present in patients with calcaneal bursitis, but obtaining a histologic specimen from an actual patient would be extremely rare.

 

Treatment

Rehabilitation Program

Physical Therapy

Gradually progressive stretching of the Achilles tendon may help to relieve impingement on the subtendinous calcaneal bursa. Stretching of the Achilles tendon can be performed by having the patient place the affected foot flat on the floor and lean forward toward the wall until a gentle stretch is felt in the ipsilateral Achilles tendon. The stretch is maintained for 20-60 seconds and then is relaxed. This technique is demonstrated in the following images.

Achilles stretch 1; whole-person view. The patient Achilles stretch 1; whole-person view. The patient stands with the affected foot flat on the floor and leans forward toward the wall until a gentle stretch is felt in the ipsilateral Achilles tendon. The stretch is maintained for 20-60 seconds and then is relaxed.
Achilles stretch 1; cropped view showing a close-u Achilles stretch 1; cropped view showing a close-up of the region affected by this type of stretch.

Another technique, a more advanced stretch that isolates the Achilles tendon, is shown in the following images.

Achilles stretch 2; whole person view. This stretc Achilles stretch 2; whole person view. This stretch, which is somewhat more advanced than that shown in Images 1-2, isolates the Achilles tendon. It is held for at least 20-30 seconds and then is relaxed.
Achilles stretch 2; close-up view. Achilles stretch 2; close-up view.

To maximize the benefit of the stretching program, the patient should repeat the exercise for multiple stretches per set, multiple times per day. Ballistic (ie, abrupt, jerking) stretches should be avoided in order to prevent clinical exacerbation.

The patient should be instructed to ice the posterior heel and ankle in order to reduce inflammation and pain. Icing can be performed for 15-20 minutes at a time, several times a day, during the acute period, which may last for several days. Some clinicians also advocate the use of contrast baths, ultrasound or phonophoresis, iontophoresis, or electrical stimulation for treatment of calcaneal bursitis.

If the patient's activity level needs to be decreased as a result of this condition, alternative means of maintaining strength and cardiovascular fitness (eg, swimming, water aerobics) should be suggested.

Medical Issues/Complications

See the list below:

  • Addressing footwear

    • Changing footwear may be the most important form of treatment for calcaneal bursitis. The use of an open-backed shoe may relieve pressure on the affected region.

    • Individuals whose symptoms have been precipitated by a dramatic footwear change, specifically, a switch from high-heeled shoes to flat shoes (or vice versa), may need to temporarily use footwear with a medium heel height.

    • Athletes should be encouraged to change running shoes on a regular basis, because the shoes' fit, as well as the support the shoes provide, may change over the course of hundreds of miles of use.

  • Further modification of shoes

    • A portion of the heel counter can be cut away and replaced with a soft leather insert to decrease friction at the site where the heel counter meets the skin.

    • Shoes without laces (eg, slip-on shoes, sandals) inherently fit closely onto the heel and should be avoided.

    • Inserting a heel cup into the shoe may help to raise the inflamed region slightly above the restricting heel counter. If this approach is implemented, a heel cup should also be placed into the other shoe to avoid introducing a leg-length discrepancy.

    • Of note, a recent prospective, randomized-controlled study has called into question the efficacy of orthotic insoles, however, suggesting that routine use of foot orthoses by healthy men provide no significant preventive benefits against overuse injuries, including bursitis.[19]

  • Immobilization

    • The initial accommodation of the bursitis by the introduction of rest or of a decrease in or modification of activity may suffice to reverse the bursitis and its symptoms.

    • If the symptoms are resistant to the above treatments, immobilization in a cast for 4-6 weeks should be considered.

  • Complications from calcaneal bursitis or its treatment

    • Progressive posterior heel and ankle pain

    • Rupture of the Achilles tendon, either secondary to chronic local inflammation/degeneration or as a result of corticosteroid injection(s)

    • Some clinicians advocate the use of corticosteroid injection(s) into the affected bursa, being careful to avoid injection within the Achilles tendon.[20] Because of the close proximity of the Achilles tendon to the bursae, such injections should be considered only in severe, recalcitrant cases. The authors of this article generally recommend against corticosteroid injection in the vicinity of the Achilles tendon because of the potential risk of tendon rupture. However, prospective, randomized studies have not been performed to establish whether steroid injections cause such tendon ruptures. Instead, the association between steroid injections and subsequent tendon ruptures is mostly based on retrospective case reports. Potentially, those cases that were more likely to go on to rupture were also more likely to have a severe presentation that prompted the steroid injections.

    • One case report demonstrated that subtendinous calcaneal bursitis can be not only diagnosed but also treated with ultrasonography. Ultrasonographic guidance can be used to inject the subtendinous calcaneal bursa with a combination of local anesthetic (eg, lidocaine, giving relief within minutes and lasting several hours) and corticosteroid (eg, Kenalog, producing an anti-inflammatory effect within 24-48 h and providing relief for weeks to months). The authors feel that using ultrasonographic guidance can help to ensure reliable, accurate delivery of medication into the bursa while avoiding intratendinous injection.[17]

Surgical Intervention

For patients who have persistent or progressive symptoms despite rigorous nonsurgical treatment, the following surgical interventions are options:

  • Resection of Haglund deformity, removing the calcaneal superoposterior prominence (ostectomy)

  • Excision of the painful bursa or bursae

  • Debridement of the Achilles insertion

  • In cases of Achilles tendon rupture or avulsion, surgical re-anastomosis is indicated.

  • Surgery for Achilles tendon rupture can be followed up by a postoperative injection of platelet-rich plasma (PRP), which has been shown to improve postoperative outcomes in the short-term and midterm[21, 22]

  • Outpatient endoscopic removal of the inflamed bursal tissue and resection of the prominent bone.[23]

A review study by Wiegerinck et al suggested that, based on patient satisfaction and complication rates, endoscopic treatment of chronic retrocalcaneal bursitis is superior to open surgery. The review included 15 trials (12 open-surgery studies and 3 endoscopic trials), which encompassed 547 procedures in 461 patients. The study also indicated that sufficient bone resection is required for a good procedure outcome, regardless of the surgical technique used.[24]

Consultations

Patients requiring surgical intervention should be referred for surgical consultation to an orthopedic surgeon who is experienced in foot and ankle surgery.

Other Treatment

As discussed above, corticosteroid injection in this region is not recommended because of the potential risk of rupturing the Achilles tendon.

Microcurrent therapy may serve as another modality for managing heel pain. Using a numerical rating scale for pain, a study showed that the addition of microcurrent therapy to traditional treatments significantly reduced pain (pain rating reduction from 8.9 to 2.3) compared with traditional treatments alone (pain rating reduction from 8.2 to 5.9). Improvement may be due to the induction of secondary messengers, such as cyclic adenosine monophosphate (cAMP), which modulates important processes for cellular viability.[25]

Other research indicates that low-dose radiation therapy may be helpful in reducing heel pain, with this modality having been associated with significant improvement in achillodynia.[26, 27]

 

Medication

Medication Summary

For this musculoskeletal condition, medications are used primarily to decrease pain and inflammation. Thus, the most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs), which are employed in conjunction with the rest of the rehabilitation plan.[28]

Nonsteroidal anti-inflammatory drugs

Class Summary

Oral NSAIDs can help to decrease pain and inflammation. Various oral NSAIDs can be used, with the choice of drug being largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Ibuprofen (Motrin, Advil, Nuprin, Rufen)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Various doses are available with and without a prescription.

Naproxen (Naprelan, Naprosyn, Aleve, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.

Ketoprofen (Actron, Orudis, Oruvail)

For relief of mild to moderate pain and inflammation.

Small dosages are initially indicated in small and elderly patients and in persons with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

Flurbiprofen (Ansaid)

May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Nonsteroidal Anti-inflammatory Drug, Topical

Diclofenac topical

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

 

Follow-up

Further Outpatient Care

See the list below:

  • The patient should return for re-evaluation every 4-6 weeks until the symptoms are resolved or under adequate control.

  • These follow-up visits provide the clinician with an opportunity to monitor the efficacy of the treatment plan and to make appropriate modifications if the patient's symptoms have not adequately improved.

Deterrence

See the list below:

  • The patient should avoid footwear that fits tightly at the posterior heel.

  • High-heeled shoes should be avoided.

Complications

See the list below:

  • Chronic or progressive posterior heel pain

  • Limping (antalgic gait)

  • Achilles tendon rupture occurring secondary to chronic inflammation or perhaps resulting from corticosteroid injection

Prognosis

See the list below:

  • Most patients respond well to a combination of local icing, oral anti-inflammatory medications, Achilles tendon stretching, and footwear modification.

  • Surgical intervention may provide good results for patients in whom conservative treatment has failed.

Patient Education

See the list below:

  • The patient should be educated in the proper performance of Achilles tendon stretching.

  • The patient should understand the rationale for appropriate footwear.

  • A patient who is considering corticosteroid injection must understand the potential risks and benefits of this treatment.

  • For patient education resources, see the Foot, Ankle, Knee, and Hip Center, as well as Bursitis.